1. DIABETES IN SUB-SAHARAN AFRICA
Dr Kaushik Ramaiya

2. The future burden of diabetes in sub-Saharan Africa
2030
2025
2010

3. Africa is experiencing a rapid epidemiological transition with the burden of non-communicable diseases esp. diabetes that will overwhelm the health care systems which is already overburdened by HIV/AIDS, TB and Malaria.
This is due to
Rapid urbanization and westernization of lifestyle
Rapidly decreasing physical activity
Changes in dietary habits
Ageing of the population

4. What is different about DM in Africa?
Decreases survival from the disease.
Most countries do not have national diabetes programmes.
Medications are unavailable or irregularly available and unaffordable.
Well-structured educational programs for the patients and health professionals are lacking..
Unequal distribution of facilities and providers.

5. Prevalence of diabetes by age group in a population of Cameroon
RISK FACTORS
NON MODIFIABLE
Age
Ethnicity/predisposition
MODIFIABLE
Obesity
Urbanization
Physical inactivity
Change in dietary habits
Age
Prevalence of diabetes by age group in a population of Cameroon
Mbanya JC et al

6. Obesity RISK FACTORS NON MODIFIABLE MODIFIABLE Obesity Urbanization
Age
Predisposition
MODIFIABLE
Obesity
Urbanization
Physical inactivity
Change in dietary habits
Obesity
Sobngwi E, et al. Int J Obes 2002

7. Childhood Obesity RISK FACTORS NON MODIFIABLE MODIFIABLE Obesity
Age
Predisposition
MODIFIABLE
Obesity
Urbanization
Physical inactivity
Change in dietary habits
Childhood Obesity

8. RISK FACTORS
NON MODIFIABLE
Age
Predisposition
MODIFIABLE
Obesity
Urbanization
Physical Inactivity
Change in dietary habits
Average percentage annual increase in urban and rural populations,

9. Physical Inactivity RISK FACTORS NON MODIFIABLE MODIFIABLE Obesity
Age
Predisposition
MODIFIABLE
Obesity
Urbanization
Physical Inactivity
Change in dietary habits
Physical Inactivity
Daily walking time in a sample of 2465 urban and rural Cameroonians (Sobngwi E, et al Int J Obes 2002)

10. TYPE 1 DIABETES: INCIDENCE
INCIDENCE/100,000 of Type 1 diabetes in Sudan (El Amin et al.)

11. Type 1 DM in Africa- Clinical characteristics of Type 1 diabetes in Africa Patients

12. Type 2 DM in Africa Data Not rare Urban > Rural IGT
increasing but limited
Not rare
low in rural areas
moderate in rural and urban areas with development
high in urban areas
Urban > Rural
IGT
early stage of epidemic
Increasing in same population
Ethnicity
Modifiable risk factors

13. SUMMARY OF CURRENT PREVALENCE OF TYPE 2 DIABETES
Rural Sub Saharan Africa 1 – 3.5%
Urban Sub Saharan Africa 3 – 7.7%
Republic of South Africa – 8.0%
Maghrebian countries – 9.3%
Indian origin populations – 13.3%

14. Complications of diabetes
Increasing prevalence of diabetes and their complications in Sub-saharan Africa are a major drain on health resources in addition to physical and social impact on an individual and community

15. Acute complications of diabetes:
Diabetic ketoacidosis
Hyperosmolar non-ketotic coma
Hypoglycaemia

16. Diabetic ketoacidosis
Common emergency
High mortality 25% in Tanzania, 33% in Kenya
Contributing factors:
Lack of insulin availability
Delay in diagnosis
Misdiagnosis
Economics
Poor healthcare system
infections

17. Hyperosmolar non-ketotic coma:
Complication of type 2 diabetes
Less common
Accounts for about 10% of all hyperglycaemic emergencies (Zouvanis et al, 1987)
Contributing factors:
Infections
Non-compliance
First presentation
Mortality high – 44% - studies from South Africa (Rolfe et al, 1995) – patients usually elderly and have other major illness

18. Hypoglycaemia Serious complication of OHA therapy
In South Africa (Gill & Huddle,1993) 33% of cases associated with sulphonylurea treatment
Other precipitating causes:
Missed meal (36%)
Alcohol (22%)
GI upset (20%)
Inappropriate treatment

19. Microvascular complications of diabetes
RETINOPATHY
year
country
prevalence (%)
1988
Zambia 34
1993
Ethiopia 13
1995
South Africa 52
1996
Cameroon 37
Burkina Faso 16
1997 55 36

20. RETINOPATHY
In South Africa, at diagnosis, 21-25% of type 2 diabetes and 9.5% of type 1 diabetes have retinopathy (Kalk et al,1997).
? Genetic predisposition – africans more affected
Poor/inadequate access to healh care leading to inadequate control of blood glucose and blood pressure.

21. Microvascular complications of diabetes
NEPHROPATHY
year
country
prevalence (%)
1996
Kenya
41*
Burkina Faso 25
Cameroon
46*
1997
South Africa 37
Ethiopia 33
*microabuminuria

22. NEPHROPATHY
Diabetes contributes to 35% of all patients admitted to dialysis unit (Diallo et al,1997)
In South African series, 50% of all causes of mortality in type 1 diabetes was due to renal failure (Gill, Huddle & Rolfe, 1995)

23. Microvascular complications of diabetes
NEUROPATHY
year
country
prevalence (%)
1988
Zambia 31
1991
Ethiopia 36
Sudan
31.5
1994
Tanzania 25
1995
South Africa 42
1997 28

24. NEUROPATHY Prevalence varies widely depending on method used.
Poor glycaemic control and inadequate foot care are risk factors for diabetic foot.

25. Epidemiology of Diabetic Foot (Abbas ZG)
40-60% of all non-traumatic amputations
85% of diabetes related lower extremity amputations
The prevalence of foot ulcer is 4-15% of diabetes population

26. MACROVASCULAR COMPLICATIONS OF DIABETES
COUNTRY
YEAR
PREVALENCE (%)
Lower Limbs Vascular Disease
(PVD)
Senegal
1994 28
South Africa
1997 8
Sudan
1995 10
Tanzania 12
Coronary Artery Disease (CVS)
Bukina Faso
1996
Uganda 5
Cerebrovascular Disease
Zambia
1988 1

27. Diabetes - Clinical course
ETHIOPIA Causes of death in 100 Ethiopian diabetic patients
At death: % of patients below age 50 years % below 10 years of diabetic duration
Causes of death: Metabolic 47 % Renal Failure 26 % Infective 12 % Cirrhosis 10 % Stroke 8 % Other 12 % Not known 15 %
Lester FT. Ethiopian Med J 1984; 2: 61-68

28. Diabetes - Clinical Course South Africa

29. Clinical course of Diabetes Tanzania (Dar es Salaam)

30. Insulin / OHA costs Tanzania (1989-90):-
Average annual direct cost of diabetes care US $ IRDM US $ NIDDM
Purchase of insulin accounted for US $ (68.2%) of the average annual outpatient costs for IRDM.
OHA accounted for US $ (42.5%) of the average annual outpatient costs for NIDDM.
Chale SS et al. For Med J 1992; 304:

31. Costs of treatment In Cameroon (Nkegoum, 2002) in the year 2001:
Average direct medical cost of treating a patient with diabetes was USD 489.
56% -hospital admission
33.5% - anti-diabetic drugs
5.5% -laboratory tests
4.5% on consultation fee.

32. Indirect cost of diabetes (Tanzania 1989-90)
Future Healthy Life Days (HLDs) lost per patient with diabetes during the 8 years of follow-up .
IRDM
NIDDM
Uncertain
Overall
Reason for lost days
(n=3626)
(n=2390)
(n=1974)
(n=4100) % % % %
Premature death
55.1
39.7
96.8 69
Disability before death
0.5
3.9
0.4 1
Chronic disability
43.3
55.7
2.4 29
Acute Illness
1.1
0.6
0.4 1
Chale SS. A study of the Economic Costs of Diabetes Mellitus in Tanzania in 1989/90. UDSM

33. This increasing burden is against a background of decreasing resources.
Therefore primary prevention must be the cornerstone of policies aimed at combating these lifestyle related diseases.

34. Prevention Strategies Problems in Africa
Mortality
Poorly skilled or inadequate providers
Delay - attention
Drugs – availability
- affordability
Complications
 awareness
 facilities– detection
- monitoring
economics

35. Barriers to Quality care
Irregular supply of medicines (including insulin)
Inadequate health-care infrastructure and disproportionate distribution of the facilities
Affordability
Lack of adequate training and retraining of health care providers
Lack of education to the people living with diabetes & their families
Differing government priorities

36. IDF AFRICA REGION - RESPONSE
Diabetes Practice Guidelines.
Diabetes Education Training manual
African Declaration on Diabetes
Training
Strengthening national diabetes associations
Research / data